Zack Hogle did not start his transition, four years ago, with genital surgery in mind.

Like most trans men, he was anxious to begin with weekly shots of testosterone, or T, the hormone that would lower his voice, trigger facial and body hair, and bulk up his thin, wiry body.

"When I got my first T shot I couldn’t believe it, I was like, 'I’m in the process of finally becoming me,' " said Hogle, who's 24 now. "I’m going to be able to stand in the mirror every day and see the man who’s supposed to be there."

Hogle then took time off from his job at a Dunkin' Donuts in the central Massachusetts town of Barre for the next step in his transition: surgery to shape a male chest.

Hogle was getting closer to the person he expected to see in the mirror, but he hated what he saw below.

"I realized, OK, from the waist up I’m a man but I’m not from the waist down, and that really got me looking into bottom surgery," Hogle said. "I was set in stone to go to California," where there are several well-known surgeons who perform female-to-male genital surgery.

A New Center At Children's

Hogle started saving money for an extended trip west about the same time that Dr. Oren Ganor, a plastic surgeon, was noticing a flurry of articles about transgender patients and surgery and wondering: Is gender affirmation surgery something we at Boston Children’s Hospital should offer? Boston Medical Center had just begun to offer male-to-female genital surgery, but no hospital in New England was performing phalloplasty.

"As a young surgeon I was trying to help patients and establish something that’s going to be meaningful," Ganor said.

Meaningful but controversial. Ganor approached Dr. David Diamond, who co-founded the country’s first gender management clinic at Children’s back in 2007. Together they took plans for a transgender surgery center to the hospital’s ethics committee. Diamond was concerned about staff who might be uncomfortable.

"If we were going to offer this surgery here, we wanted to know that it could be done in an environment that was supportive of these patients," said Diamond, urologist-in-chief at Children's. "We needed the staff to understand what we were trying to achieve. And we needed there to be an opt out."

Hospital leaders supported the effort. Children's approved the Center for Transgender Surgery in December 2017 to perform female-to-male and male-to-female genital procedures, as well as chest reconstruction surgery.

Ganor said he doesn’t know of anyone on staff who asked not to be assigned to transgender surgery patients. Instead, he had more requests to join the team than he could handle. He scheduled staff trainings because there were lots of questions.

"'What are the things I’m allowed to ask? What am I not allowed to ask? How to approach the patient? There’s the legal name but there’s the chosen name' — all of these small things kept many people afraid," Ganor said.

With the surgery center, Children's is now the first hospital in Massachusetts to offer phalloplasty, and said it is the only pediatric hospital in the U.S. where patients can get this procedure.

"It’s consistent with Children’s' willingness to take risks on certain things and to be a little bit bold and to do what it thinks is the right thing," Diamond said. "I'm proud to be part of this."

Children's is prepared for an angry response from those who believe the hospital's role should be to help patients who are uncomfortable with their body learn to live in it.

"That view is held fairly widely," Diamond said, "but when you have the opportunity to speak to these patients and learn about their history and how far back their sense of gender dysphoria began, you become impressed that this is something that's very real."

Hogle is Children's' first and only phalloplasty patient so far. The hospital expects to have one or two such patients a month by early next year.

While Children's is a pediatric hospital, patients will have to be 18 or older for phalloplasty. This is in keeping with international guidelines that suggest waiting until the patient is an adult to avoid regret.

The most recent data on transgender patients who change their mind after surgery is a study led by Oregon Health and Science University, which has not been published but was presented at a conference earlier this month. In it, 46 surgeons from around the world reported reversing 36 transgender surgeries, including 16 phalloplasties, after treating somewhere between 18,000 and 27,000 patients.

Children's, Ganor said in an email, is "slightly flexible" when it comes to the age of transgender girls seeking genital surgery "because of the difficulty young women can experience accessing gendered spaces — like dorms and bathrooms — if they still have male genitalia." That policy has not been finalized, he said, "because of the issue around consent for sterilization (which is part of the procedure).”

Children's does not typically care for patients older than 35, although that cap is under review because patients seeking phalloplasty do not currently have any other local option.

The Surgery, And Complications

Doctors took a rectangle of skin, tissue and blood vessels from Hogle's right forearm to shape a penis. (Robin Lubbock/WBUR)

Hogle heard from a nurse at another Boston hospital that Children's planned to offer phalloplasty. He met Dr. Ganor and, at the end of January, checked in for what turned out to be a 14-hour-surgery. Doctors took a rectangle of skin, tissue and blood vessels from Hogle's right forearm to shape a penis and extend the urethra to the tip. Hogle was in and out of the hospital for several weeks with complications.

At home Hogle had extended bladder spasms. He praises the doctors and nurses at Children's who unclogged his catheter, tended to his arm, and fixed problems he had passing urine through the new penis.

A blocked or leaking urethra is common among phalloplasty patients, with 30 to 50 percent seeking treatment for one of these problems, said Amir Taghinia, a plastic surgeon who is a member of Children's transgender surgery team. Taghinia expects that rate will improve as more phalloplasties are performed in academic medical centers like Children's.

"Many of these procedures in the past have been done in private practices," Taghinia said. "We at Children's have the resources to look at these types of procedures through many different angles and develop ways of improving those."

Other surgeons agree but urge patience. Dr. Richard Santucci is a senior surgeon at Brownstein Crane, with offices in Austin and San Francisco, where he says physicians have performed more than 400 phalloplasties. He expects incremental annual improvements in complication rates, in the range of 2 percent.

"We're in a dawn of new surgical sophistication with this operation, with honing of the technique in established centers and new and competent centers taking on the challenge, and that's a very good thing," Santucci said.

Some trans men say there's an important psychological component to discuss with patients considering phalloplasty: the phantom penis. It's the idea that trans men, like patients born without a limb, develop feelings tied to the missing body part. One small survey, of 30 trans men, found that more than half reported experiencing a phantom penis.

"It's a whole other physical dimension and sensation," said S.J. Langer, a psychotherapist in Manhattan who is conducting a larger survey on the topic. "Anything we can use to help people feel more embodied and to feel more connected to their bodies, the better clinical outcomes we'll have."

Children's says it plans to start a phalloplasty support group where patients could discuss phantoms and related concerns.

Many trans men do not pursue phalloplasty because of the high complication rate or because they feel complete without a penis. The cost, which can range from $20,000 to $40,000, is another barrier for many, especially because phalloplasty is not routinely covered by insurance. For Hogle it was — and would be for most patients in Massachusetts.

'I Am Complete'

Brittany Sandman and Zack Hogle at Barre Dam (Robin Lubbock/WBUR)

Despite the long recovery, Hogle is thrilled with the results.

"I am the happiest I have been in my entire life," Hogle said on a sunny morning at a park near home, where he comes to relax. "I am complete. I am who I should be. I can finally look down and see what I’ve been wanting for so long."

Hogle's girlfriend, Brittany Sandman, sat next to him on a picnic bench. Hogle and Sandman are open about their sex life. Hogle can't have erection with the penis Children's constructed; he'll have to go back and have a prosthesis implanted, which he hopes to do. But he can have an orgasm.

"He's gotten pretty lucky with that," Sandman said, laughing.

"I'd say very lucky," Hogle added.

"It's a lot about keeping in mind where the clitoris was," Sandman said.

The sex talk wrapped up as Hogle's mom, Tina Murphy, approached the table. Hogle says his father has disowned him but his mom and stepfather have supported him through the transition. Murphy said she has no doubts about all the surgery Hogle's had. She's grateful for the doctors who turned her sad little girl into a happy young man.

"It's amazing, the change in him, he's a new person, literally," Murphy said.

Hogle’s phalloplasty transformed some of his doctors and nurses as well. Nancy Mackie was in the OR for all 14 hours of Hogle’s surgery. She said meeting Hogle and being part of his team is the best experience she’s had in 40 years of nursing.

"At first I felt a little silly for the way I felt," Mackie said, "but I realized that we were totally changing his life and making it so much better. I just never thought I’d be in that position. It was incredible."

Mackie says she’s struggled to explain the experience to her husband and some friends who don’t agree with transgender surgery.

Children’s is prepared for those calls — but also lots of calls from interested patients. Santucci says his practice performs up to five phalloplasties a week. The waiting list ranges from three months to a year and a half, depending on the surgeon. Those patients who've been flying in from the Northeast now have another option, closer to home.

Correction: Due to an editing error, an earlier version of this article included an incorrect number of surgeries from the Oregon Health and Science University study. We regret the error.